Access to and interventions to improve maternity care services for immigrant women: a narrative synthesis systematic review

Cultural competence

Meeting the maternity care needs of diverse populations demands consideration of the issues of cultural safety and cultural competence. Leininger,52 a seminal theorist, described ‘culturally competent care as care that is sensitive and meaningful to the patients, that intersects well with their cultural beliefs, norms and values’. This type of care may consist of actions that identify, respect and promote the cultural uniqueness of each individual. 53 These important behaviours may be enhanced by continuing education for nurses and other health-care providers. 54 Although Leininger made an important contribution in this field in the last century, her work has been critiqued extensively,55 largely for its assumption that care and services will be improved by knowledge of different cultures without recognition of ‘the very complex ways in which race, socioeconomic status, gender and age may intersect’. 56 The approach tends to promote culture negatively, potentially contributing to stereotypical attitudes and propagating power imbalances. 57 Serrant-Green58 stressed that the diversity within all ethnic communities needs to be addressed.

The term cultural competence means different things to different people; it can be said to represent a diverse set of skills, knowledge, attitudes and behaviours. Cultural competence can operate at the level of the individual practitioner, within a service setting, and at the broader levels of the health-care organisation and in the wider health-care system.

Key dimensions of cultural competence are the following:

• knowledge about diversity in beliefs, practices, values and world views, both within and between groups and communities, and recognition of similarities and differences across individuals and groups, as well as the dynamic and complex nature of social identities (sometimes called cultural knowledge)

• acceptance of the legitimacy of cultural, social and religious differences, and valuing and celebrating diversity (sometimes called cultural awareness)

• awareness of one’s own identity, beliefs, values, social position, life experiences and so on, and their implications for the provision of care (sometimes called cultural awareness or reflexivity)

• understanding of power differentials and the need to empower service users (sometimes considered part of cultural awareness)

• the ability to empathise, show respect and engender trust in service users (sometimes called cultural sensitivity)

• recognition of social, economic and political inequalities and discrimination, and how these shape health-care experiences and outcomes for minority groups; and a commitment to address such inequities

• effective communication strategies, including resources for cross-lingual and cross-cultural communication

• resourcefulness and creativity to resolve issues arising during the provision of care across differences. 59

Organisational cultural competence

Organisational cultural competence refers to the structures, processes and strategies that operate within health-care organisations, to ensure the delivery of high-quality care and equitable outcomes to all clients, regardless of their ethnic, cultural or religious identities. This type of competence usually encompasses critical reflection on the inner workings of the organisation, including the underlying ways of operating that serve the interests of the dominant group within society. Cultural competence at an organisational level involves the commitment of adequate resources to support appropriate responses at the service delivery level.

Cultural safety

Culture is one of the most difficult terms or concepts to define, but is usually taken to be the beliefs, values, practices and symbols that are recognised by individuals who belong to a particular ethnic group. Although our focus here is on cultural safety,51 the issue of intersectionality must be acknowledged, because in reality a number of axes of inequality exist. For example, social class, ‘race’, ethnicity and gender intersect with culture and may increase the vulnerability60 of women in accessing maternity care services. Focusing on a narrow definition of culture when providing health care may lead to the stereotyping of clients and potentially to an inability of the practitioner to deal with diversity. Cultural safety aims to address these deficits by considering the historical and social processes that impact power relationships within and beyond health care. 50,51 Cultural safety is achieved when programmes, instruments, procedures, methods and actions are implemented in ways that do not harm any members of the culture or ethnocultural group who are the recipients of care. 61,62 Those within the culture are best placed to know what is or is not safe for their culture, which suggests the need for increased dialogue with immigrant women and a need for collaborative partnership approaches. 63,64

Cultural safety was first conceptualised in New Zealand by Dr Irihapeti Ramsden, a Maori nurse, in response to a need to acknowledge the impact of colonisation on the Maori population and its lasting effects in the provision of health care. 63 Ramsden conceptualised cultural safety as a product of nursing and midwifery education that facilitates culturally safe care as defined by the recipients. 50 Cultural safety has been endorsed by the Nursing Council of New Zealand64 and has been a key component of international nursing and midwifery education since the early 1990s. The concept is less commonly used in the UK context, although it seems to be eminently transferable and has a strong empirical basis which other models do not have. Hence, it has been adopted as the cultural safety model by statutory bodies in both New Zealand and Canada. 62

In the current period of superdiversity3,20 in the UK, responding to diverse needs of immigrant women in maternity care is an urgent imperative. 8,37 It would seem necessary to draw on the concepts of cultural safety51 and cultural competence65 in order to provide optimal care, the fundamental axioms and precepts being that the values and norms of the host community determine the service configuration and in fact NHS employees are the bearers of these cultural norms via professional practice. Other nation states, notably Canada,62 Australia and New Zealand,50,63 have integrated the key dimensions of cultural safety (e.g. into professional education for HCPs). Intersecting the primacy of host community values is the idea within the notion of cultural safety, that power dimensions exist between the dominant cultural groups and new ethnocultural groups, resulting in unequal power dimensions in the health-care interaction. These unequal power dimensions often have historical antecedents; an exemplar of this is the notion that Commonwealth immigrants arriving in the UK, and in sociological terms, may be regarded as ‘the other’. Culturally competent and safe care demands not just a focus on individual professional practice, but an embedding of the principles of culturally safe and competent maternity care at the organisational level via policies, procedures, guidelines, education and training of health professionals.

Protocol and PROSPERO registration

Our study is registered with PROSPERO as CRD42015023605 (URL: www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015023605; accessed 5 June 2019) and the protocol has been published. 84

Element 1: developing a theory

This review had no predefined hypotheses. Our review focus on immigrant women’s access to and interventions in maternity care was developed and refined by mapping the available knowledge, and also ensuring the relevance of the knowledge synthesis (to policy-makers, other potential knowledge users and immigrant communities). The literature spanned a range of specific maternity care services, including antenatal, labour and postnatal care; maternal risk factors; health promotion; access to and availability and competency of maternity services; the role of culture and tradition; maternity outcomes in relation to perceived maternal risk factors; and responses to care interventions. We engaged in additional consultation with our PAG to further refine the review questions to increase their relevancy. We utilised Gulliford et al. ’s23 theory of access to inform our thematic outcomes (Box 2 gives an example of the scoping search strategy and Appendix 1 gives an exemplar of a final search strategy).

Search strategy and study selection

We included all empirically based studies that used a variety of methodologies (see Appendix 2) and focused on immigrant women, maternity care experiences, experiences and interventions, published between January 1990 and January 2018. Studies were published in English and included study locations in the UK (Table 1). We found several studies arising from Scotland and one from Wales; the remaining studies were based in England (see Appendix 3 for the table of excluded studies).

The NS approach relies primarily on the use of words and text to summarise and explain the findings of the synthesis, which are informed by a synthesis of the narrative findings of included papers. 86 Gina Higginbottom and Myfanway Morgan have successfully employed this review genre previously and have vast expertise in its usage. 87 Narrative synthesis is suitable for both quantitative and qualitative studies, as the emphasis is on an interpretive synthesis of the narrative findings of research, rather than on a meta-data analysis. 86 After applying rigorous systematic procedures for searching, screening and selecting literature for inclusion in the review, the articles were appraised for quality and the NS of the findings progressed.

We included studies that focused on immigrant women and adopted the following definition of an immigrant woman for the purposes of our review. A woman is an immigrant if she:

• is born outside the UK

• has lived in the UK for > 12 months or had the intention to live in the UK for ≥ 12 months when she first entered the UK.

Therefore, we included studies on immigrant women in which the population studied fulfilled these characteristics. Based on this, studies that focused on the following population groups were also eligible for inclusion: foreign students, asylum seekers, illegal immigrants and recent legal refugees and immigrants. In many cases the study populations/sample was not accurately and fully described. We therefore used linguistic ability (e.g. the need for an interpreter as a proxy for immigrant status). Our focus was on first-generation immigrant women regardless of their phenotype. Meaning that women of all ethnic groups are including women of white ethnicities, although we encountered few studies that focused on the latter and our review was constrained by the lack of various studies in the scientific literature. For example, we did not identify any studies meeting our criteria that focused on solely white immigrant women, such as Eastern European women.

The search and selection strategies drew on established systematic review methods88 and incorporated recent guidelines for the selection and appraisal of grey literature. 89 Two search and selection phases were conducted. The first consisted of searching electronic databases and websites of relevant journals to identify empirical papers published in peer-reviewed journals. We considered empirical papers to be primary research publications that investigated working hypotheses or research questions and tested them by means of observations or experimentation, qualitative investigation or mixed-methods designs. The second phase targeted grey literature and included searches of selected databases, internet-based searches (see Report Supplementary Material 1), reviews of reference lists, and e-mail or telephone contacts with researchers and other stakeholders that had expertise or interest in the target topic. The processes we used to conduct the search and selection process are summarised in Figure 3.

FIGURE 3.

Summary of the search and selection methodology. Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Our focus was on access and interventions designed to promote or enhance maternity care for immigrant women, as articulated in the original review question. We chose the definition of intervention to be an integration of program facets or strategies designed to create behaviour changes or enhance health status amongst individuals or an entire population’. 90 In fact, in practice we identified few interventions that have been rigorously and scientifically appraised (that is not to suggest that these interventions do not exist, merely that they have not been evaluated).

We adopted the population, intervention, control and outcome of interest (PICO) approach to implement the search strategy as follows:

• population – immigrant women

• interest – maternity care

• control – non-immigrant women (implicit comparator emerging in the results)

• outcome of interest – experience of care.

Therefore, our search strategy development was based on:

• search concept 1 – pregnancy, childbirth (implicitly females requiring maternity care), explicit terms covering women/females requiring all types of maternity care (antenatal, perinatal, postnatal, etc.)

• search concept 2 – immigrant populations (which would not fully distinguish between ‘new’ and ‘second-generation’ immigrants, this would be done at the selection stage)

• search concept 3 – terms used to identify access to, use of, deficiencies in, etc., service provision (to help identify groups with poorer health outcomes or vulnerabilities)

• our final answer set of citations included concepts 1, 2 and 3.

Development of literature database search strategies and search implementation

Team member Jeanette Eldridge is an experienced information scientist with whom we developed the scoping search strategy (see Box 2). An exemplar of final search strategies (see Appendix 1) incorporated revisions, as per the knowledge base of the academic team members (GH, MM, KB and CE) and included internet and literature database searches. Jeanette Eldridge constructed the detailed search strategies for each literature database and conducted the searches after review of these strategies by the entire team, including the PAG. The search focus was on studies that described access and compared interventions to improve maternity care experiences for immigrant women in the UK (Box 3).

Search implementation included independent double-screening and team review of ambiguous studies. Our search strategy was adapted for each of these databases so that relevant controlled vocabulary, searching techniques and keywords were used consistently. The reference lists of the included studies were reviewed for relevant citations. Additional hand-searches were undertaken of major relevant journals (e.g. Journal of Immigrant and Minority Health, Journal of Health Services Research & Policy and Canadian Journal of Public Health) and in reviews published by topical research groups (e.g. Reproductive Outcomes and Migration, an international research collaboration). 41

We used a screening tool (see Table 1) to select studies congruent with our review questions (Box 4) and to ensure robustness of the NS. 86 A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)91 flow chart illustrates the selection process that we implemented (Figure 4).

FIGURE 4.

The PRISMA flow chart of the final selection process. Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

We included studies that focused on immigrant women; therefore, we included studies on immigrant women in which the population studied fulfilled the characteristics previously mentioned (see Search strategy and study selection).

A relevancy appraisal of each record was undertaken by first reviewing the title and abstract (GH, CE, MM, JE, KB and BH). Records were shared with team members via the EndNote, Version 7, collaborative function (Clarivate Analytics, Philadelphia, PA, USA). We retrieved potentially relevant articles for further assessment against our inclusion criteria, with the entire team making the final decision. We used a PRISMA flow chart (see Figure 4) to document the steps used in the search and selection process. 91

Element 2: developing a preliminary synthesis

Our analysis process began with the selection of included papers by the research team, with the final selected papers being reviewed by one researcher and the data of each paper extracted into a one-page textual summary (see Appendix 5). A second team member confirmed the study selection; furthermore, the entire team confirmed the selection at the reflective team meeting. We shared advance information with team members prior to meetings so that views could be elicited in an efficient fashion, with careful recording of views and decision-making processes in meeting minutes. Meetings included incisive debate regarding contentious papers. Team members Myfanwy Morgan, Catrin Evans and Gina Higginbottom are experienced systematic reviewers (evidenced in previous publications94), so we harnessed this expertise for the benefit of this review; pertinent practice perspectives by CM and Janette Eldridge provided technical systematic knowledge.

We engaged in careful reading and re-reading of papers to ensure familiarisation with the content. Once the final selection for inclusion was established, we undertook a tabulation of key variables of all included studies and an exemplar can be found in Appendix 5. Tabulation and extraction of key findings was facilitated by the production of the one-page textual summaries, as this format facilitated comparison and contrast of study findings in a systematic and coherent fashion.

The project principal investigator (GH) also undertook a detailed analysis of the narrative findings of each study using ATLAS.ti computer-assisted qualitative data analysis software, engaging in a line-by-line analysis of the narrative findings of each included study. The analysis created over 250 codes. The two perspectives were then merged to create a cohesive interpretation. The aforementioned processes are human resource intensive, iterative and demanded reconsideration several times. However, differences in interpretation between the researchers may still exist, although these differences are likely to be marginal and will not have an impact on the critical conclusions and implications for practice. Inevitably, the perspectives and foci of the research studies included limit our conclusions.

In element 2 (Table 2), we also applied the critical appraisals tools, made an appraisal and included this in the one-page textual summary we created (see Appendix 5).

We proceeded to group and cluster the studies in respect of the data extracted for the textual description. This enabled identification of patterns between and within studies. During this grouping process, the research questions remained salient in our cognition. A particular feature grouped data, for example the method, the country of origin of the sample studied, the maternity care setting, or the main findings. We identified major themes in the narrative findings (see tables in Report Supplementary Material 1).

Following construction of the preliminary themes, we produced code/narrative theme tables to demonstrate how the basic meaning units related to the theme, utilising the codes produced in ATLAS.ti and aligning these to the manually extracted key findings. We defined codes individually in ATLAS.ti, enabling the essential meaning of key phenomena to be captured, facilitating cross-comparison and variations in phenomena to be established and observed. Codes are defined by Miles and Huberman95 as:

. . . tags or labels for assigning meaning to the descriptive of inferential information compiled during a study. Codes usually are attached to ‘chunks’ of varying size words, phrases, sentences or who paragraphs, connected or unconnected to a specific setting. They can take the form of a straightforward category label of a more complex one (e.g. a metaphor).

Miles and Huberman, p. 5695

‘Code families’ can be produced in ATLAS.ti and imported into the graphic ‘network builder’ in ATLAS.ti, resulting in topical or hierarchical graphic outputs. We assigned the codes to code families as illustrated in Figure 5, which shows all the codes associated with code family entitled ‘communication’. This code family is a constituent of theme 3 and serves as an exemplar of the extensive analytical work undertaken. ATLAS.ti facilitated a more sophisticated and nuanced analysis than via manual extraction. These data contributed to the production of a descriptive narrative in respect of each theme. Moreover, we created a tabular matrix illustrating how the themes that occurred are distributed over the individual studies (see Appendix 6). This distribution, to some extent, illustrates the weight of evidence in each theme.

FIGURE 5.

Graphic representation of communication theme using ATLAS.ti. HCP, health-care professional. Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

During the analytical processes we interrogated the data identifying using the following concept suggested by Roper and Shapira:96

• setting – the environment or context

• activities – patterns of behaviour that occur often

• events – rare and infrequent activities

• relationships and social structures – kinship, friendship, bonds, enemies, hierarchical

• general perspectives – the group’s shared understandings

• specific perspectives on the research topic(s) – how people understand the phenomena

• strategies – ways of achieving goals

• process – flow of events how things change over time

• meaning – significance and understanding of behaviour

• repeated phases – depictions of thought processes.

We presented these analytical processes and products at our reflective team meetings to ensure the rigour and robustness of our analytical steps. Through reflection and debate, team members were able to challenge initial interpretations, identify outliers and confirm the coherence of emerging interpretations. Team members independently produced interpretations of the possible meanings of these preliminary themes in order to achieve abstraction, prior to formulation of the higher-level final themes.

Our thematic findings are evolved via a systematic, comprehensive and thorough collaborative team process of comparing and contrasting the emergent themes to establish the ways in which these themes revealed and provided insights into the concepts embedded within the review questions. This iterative process, similar to qualitative research, involved deconstructing the narrative findings into meaning units and social processes as they manifested in the maternity care experiences of immigrant women. As mentioned, individual team members engaged in independent theming of tabular and coded data. We subsequently merged these individual perspectives to form the final harmonised themes, representing a ‘meta-inference’ in respect of the narrative findings of the included studies. Meta-inference is a term used in mixed-methods research to describe the merging of findings from the positivistic and the interpretative paradigms, as is the case in this NS. Tashakorri and Teddlie97 describe meta-inference as ‘an overall conclusion, explanation of understanding developed from the integration of inferences obtained from the qualitative and quantitative strands’.

We have constructed the themes in an indicative fashion (i.e. containing implicit indications) to provide tangible guidance for policy and practice that might be developed into transformational policy- and practice-relevant strategies that will benefit immigrant women and the NHS.

Element 3: exploring relationships within and between studies

Patterns emerging from cross-literary comparisons were subjected to further rigorous evaluation to identify factors that may explain differences, including variance in women’s experiences, in the effects of maternity interventions and in the implementation of maternity services (entire team involvement). This evaluation contributed to our understanding of barriers and enablers that shape maternity services for immigrant women. We also evaluated not only the relationships between the study characteristics and the reported findings, but also the ways in which these relationships may correspond with those reported in other types of literature, including non-empirical and grey literature (which was evaluated separately). Careful attention was paid to the heterogeneity of research methods, methodologies and population characteristics encompassed in the literature through the application of narrative methods. 98 Such methods are particularly suited to synthesising such findings. 86 Narrative methods99 help us to understand and acknowledge the broader influences of theoretical and contextual variables, such as race, gender, socioeconomic status and geographical location. These methods also enable researchers to understand the shaping of differences between reported outcomes for various study designs, in this case those related to childbearing populations, and the development and implementation of maternity services and health interventions across diverse settings.

Grouping and clustering

The data extracted in the tabulation allowed papers to be grouped and thus enabled patterns between and within studies to be identified. Groupings were organised by a particular feature (e.g. location, method, ethnic groups, form of analysis, or main findings) (GH, CE, BH and the PAG).

Thematic analysis

Systematically recurrent or salient themes or concepts across studies were identified. ATLAS.ti was used to manage the data and relevant themes were identified on an inductive basis. We generated over 250 codes in ATLAS.ti and these were mapped against the tabular thematic analysis (see Figure 5).

Ideas webbing and concept mapping

‘Ideas webbing’ conceptualises and explores connections among the findings reported in the review studies and it often takes the form of a spider diagram. ‘Concept mapping’ links multiple pieces of information from individual studies using diagrams and flow charts to construct a model with relevant key themes (all team members were involved).

Critical reflection

Popay et al. 86 recommended that a summary discussion of the synthesis should be provided, which includes the following: (1) methodology of the synthesis, focusing on the limitations and their possible impacts on the results; (2) evidence used in terms of quality, reliability, validity and generalisability (for quantitative papers), and possible sources of bias (for qualitative papers); we applied the principles of Lincoln and Guba100 (confirmability, transferability, credibility and dependability); (3) assumptions made; (4) discrepancies and uncertainties identified, and how discrepancies were handled; (5) areas in which evidence is weak or non-existent as possible areas for future research; and (6) whether the evidence is ‘thick’ or ‘thin’ and the similarities and differences in the evidence (entire team).

Element 4: rigour, reflexivity and the quality of the synthesis

Reflexivity in research demands a self-conscious and explicit acknowledgement of the impact of the researcher on the research processes, interpretations and research products. Reflexivity also requires acknowledgement of inherent power dimensions, hierarchies and prevailing ideologies that might influence interpretations and subsequent knowledge production and research products. Our social identities, gender, sexuality, professional socialisation, ethnocultural orientation and political lenses further coalesce to provide a specific perspective on any given phenomenon.

The review team members come from diverse ethnocultural backgrounds and have researched in the fields of ethnicity and health for > 20 years in several global contexts, conducting many externally funded studies. We are imbued with a strong personal and professional commitment to the eradication of inequalities and allegiance to contemporary equality and diversity agendas. From a reflexive perspective, this is important given that immigration is a global phenomena and given the inherent vulnerability of some immigrant women.

Reflexive analysis alerts us as researchers to emergent themes and informs the formal and systematic process of analysis. Murphy et al. 105 define reflexivity as:

. . . we mean sensitivity to the ways in which the researcher’s presence in the research setting has contributed to the data collected and their own a priori assumptions have shaped the data analysis.

Murphy et al. 105

Team members hold a deep knowledge of the semantics associated with describing ethnocultural groups and study populations, which varies between global and sociopolitical contexts. The term immigrant is regarded as pejorative in nature in some contexts. We hold deep understandings of ideologies that manifest in research, publications and, indeed, funding and review processes. Two team members are immigrants to the UK and two team members are UK citizens who have been immigrants to other countries. Of note is that the primary researcher and post-doctoral fellow was a male researcher of Pakistani heritage, which may have created some implicit threats/bias to the interpretation of findings and data. We believe our reflective team meetings, consensus decision-making and incisive debates mitigated these tensions.

Our reflective team meetings enabled and facilitated challenges to primary selection of included papers, emerging interpretations and the extent to which individual subjective lenses had influenced these decisions. The development of themes included an exercise undertaken independently by each team (five team members and one PAG member). Our joint deliberations necessitated the constant review and reading and, in some cases, reviewing the theme allocation and evidence. Therefore, we achieved a refined and nuanced approach, gaining insights into the focus of review.

All decisions and processes were reviewed in reflective team meetings by the research team in order to achieve consensus in decision-making. In our proposal (submitted to the NIHR in 2016) we elected to use the newly conceptualised CERQual, owing to the interpretive nature of our review with a focus on narrative findings. This relatively new tool maps out pertinent dimensions demanding consideration of each individual review finding, considering four dimensions: (1) methodological limitations; (2) relevance, meaning the extent to which the relevant study findings interface with the review question; (3) coherence, that is, the extent to which the finding is grounded in the data from the relevant studies; and (4) adequacy of data, an assessment of the richness of the data informing the finding.

We applied these dimensions to our NS findings that arose from qualitative, quantitative and mixed studies, following personal communication with a CERQual author (Dr Andrew Booth, ScHARR, University of Sheffield 2018),104 regarding the utility of CERQual to our NS. Booth agreed that a modified version may be applicable. We developed and applied this modified version. However, we found the application of CERQual to be problematic because the concepts embedded within it are wholly orientated towards qualitative research. There is little guidance on applying this tool, although team members did engage in an online workshop. In our view, this tool is not wholly orientated towards a NS review. Nevertheless, we did engage in this process and, certainly for the qualitative papers, established a moderate to high level of confidence and relevance in respect of our included studies.

Within the published NS reviews we have seen little evidence of attention to publication bias; however, we sought to eradicate any potential bias by undertaking a comprehensive and exhaustive literature review that included grey literature and follow-up e-mails with authors seeking greater clarity and explanation of opaque issues. A number of the included research studies were identified via ProQuest and e-Theses and do not appear as publications in peer-reviewed scientific journals.

At our national research symposium, we presented our preliminary findings to a wide range of health professions: obstetricians, GPs, midwives, two immigrant women with experience of maternity care services, academics, and voluntary and community workers (see Report Supplementary Material 2). The approach can possibly be considered contentious in respect of systematic review, as participants have no knowledge of the original included papers but do hold deep topic knowledge. However, we found broad support for our findings and facilitated group work activities in order to challenge our initial interpretations. These challenges resulted in the construction of theme 5 (discrimination, racism, stereotyping, cultural sensitivity, inaction and cultural clash in maternity care for immigrant women). These focused activities collectively contribute to the confidence in the review findings, providing verification and validation of the themes.

Individual and group work at the symposium focused on four questions (Box 6). The symposium programme consisted of six sessions and is contained in Report Supplementary Material 2. We shared preliminary findings from the review along with commentary from a GP (CM), on the implications of the findings for practice, and a critical race theorist (KS, Director of Centre for Research on Race and Rights, University of Nottingham). Two recent immigrant women (service users) also shared their experiences of using maternity care services in the UK. The participants were afforded the opportunity to reflect on the implications of the findings for policy and practice both individually and in small groups.

Our event also included immigrant women with experience of maternity care services who gave presentations regarding their experiences (see Report Supplementary Material 2). We used the event to confirm the credibility of the team’s interpretation and synthesis of the included studies. We gave presentations regarding the theme and then elicited comments. The additional comments elicited at the event were used to inform the discussion; we have not used any of the information elicited in the actual themes, as these are based on the scientific research evidence.

Practical challenges

Conceptual challenges

We observed that authors used a variety of terms to identify participants. Terms used included BME, disadvantaged, immigrants, South Asian origin women, Somali women, Somali refugee women, Palestinian women and Chinese women (including women from Hong Kong, Taiwan and mainland China). However, the term ‘Chinese’ could be used without clearly specifying whether or not the women were born outside the UK. It could refer to immigrants or to UK-born participants who still shared Chinese culture, beliefs and experiences, or to their parents who were born elsewhere. 106 The titles and abstracts alone were often insufficient to make a decision about exclusion, so we read all the papers in detail. When there was a lack of clarity about the study sample, we contacted the authors to ask whether or not the participants were immigrants. Maintaining a contemporary contact list of these authors was challenging, as some of them had retired or held new positions. Our first step was to e-mail the authors to confirm immigrant status. In some cases, however, no valid e-mail address was available.

Challenges were accounted identifying specific findings for immigrant women in mixed population studies.

Studies included in the review, findings and evidence

Overview of the included studies

Our systematic review using NS86 identified 40 research studies in the scientific and grey literature. A broad range of ethnocultural groups and methodological genres are included in this review (see Appendix 6 and Figure 6 for theme development).

FIGURE 6.

The total numbers of studies involved in each theme. Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Methodological genres

Qualitative studies

Of the 40 studies included in this review (Figure 7; see Appendix 2), we identified 22 as qualitative research studies, employing a range of qualitative methodologies and approaches. 4,107–127 However, many of these studies did not specify a qualitative methodological genre, but instead employed a more generic qualitative approach and described only the data collection tools used. For example, some presented multiple longitudinal case studies of participants (asylum seekers and refugees), about their maternity care experiences that included photographs taken by the participants, field notes and observations, in addition to researcher interviews. Another example109 was a case study of an ethnocultural group, immigrant women of Somali origin, that used semistructured interviews and focus groups. Some studies used focus groups and interviews conducted in the language of the population group, for example Bengali, Sylheti, Urdu and Arabic. Others used in-depth interviews, open-ended questions, group story-sharing sessions and individual biographical life-narrative interviews. By contrast, a few studies specified a qualitative interpretive approach, which used hermeneutic phenomenology and focused ethnography.

FIGURE 7.

The range of publication dates for the included studies (1990–2016). Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Quantitative studies

We identified eight quantitative studies that used a questionnaire as a tool for data collection. 14,49,128–133 All of these population-based studies and cohort surveys were cross-sectional; none was longitudinal.

Mixed-methods studies

We identified 10 mixed-methods studies using a range of designs (i.e. these studies employed both qualitative and quantitative dimensions). 3,20,47,134–140 For example, Duff et al. 134 reported a two-stage psychometric study in which focus groups and interviews were used in the first stage to develop a questionnaire for an ethnocultural group (Sylheti). In the second stage, quantitative methods were used to test and evaluate the acceptability, reliability and validity of the questionnaire. Other mixed-methods designs included (1) interviewing a small sample of the participants after collecting data from a large-scale survey; (2) conducting semistructured interviews with a small sample of participants based on quantitative data routinely collected from a large group of participants; and (3) using face-to-face, postal and online questionnaires to collect data. One of the studies used Q methodology, which uses questionnaires with structured and unstructured questions.

Gaps in the evidence

Few studies focus on (1) recent immigrant and refugees (e.g. from Eastern Europe or Syria) or women of white ethnicities; (2) intrapartum care and immigrant women; (3) quantitative work using sophisticated analyses of relationships, predictability or socioeconomic variables relating to immigrant women and maternity care needs; and (4) economic analyses.

Antenatal services: accessibility and utilisation by immigrant women

Conclusion

Evidence from our included studies indicated that many participants experienced several accessibility barriers to maternity care. They also faced many challenges in uptake and continuing to utilise these services because of perceived insensitivity to their culture and religious needs. The system was also reported as being designed primarily for the general population and not for immigrant women, highlighting the ways that the health-care system may not currently accommodate diversity.

Gaps in the evidence

More studies are needed relating to interventions and their effectiveness in enhancing accessibility and utilisation of maternity care for immigrant women.

Relationships with midwives

From the perspective of immigrant women, a good relationship with the midwife is established when the midwife is caring, kind and helpful in enabling the needs of the immigrant women to be met. 127 However, we identified substantive evidence indicating that the immigrant women born outside the UK continue to be unclear on the role of the midwife in meeting their maternity care needs. 138 This lack of clarity may be due to different perceptions of doctors and midwives in the birth countries of the participants. For example, most of the maternity care needs during the antenatal phase in the UK are provided by midwives, whereas pregnant women with physiologically uncomplicated pregnancies in some other countries (e.g. South Korea and Pakistan) visit gynaecologists and medical doctors for maternal check-ups and medical tests. 127

We identified variability in the quality of, and perceived satisfaction with, the relationships between midwives and immigrant women in different maternity care settings. For example, in a study110 involving asylum-seeking women and maternity care services, high levels of satisfaction with antenatal care were expressed and some of the women had good relationships with their community and specialist midwives:

I received information about depression that women may have after having baby. This gives me some comfort that this may happen to all of us. It was important for me not to feel ashamed that I feel depressed and where I get support. It was very useful for me.

Susanne, Czech mother140

However, relationships during labour and postnatal periods were sometimes reported to be poor, with some, but not all, women experiencing perceived racism, indifference, rudeness and disrespect, as well as feelings of being powerless and coerced. 110 When seen through the lens of the previous considerations of surveillance, racism and causing ‘trouble’ within the system, these issues suggest that more systemic dynamics may be at play, which are less to do with the insensitivities of some, but not all, individual members of staff and more indicative of a system-wide framing of service delivery and care for immigrant women who may disadvantage them because of assumptions about their experiences and capabilities.

The findings suggested that asylum-seeking black women of unspecified African origin perceived that some of the care and health-care practices were coercive. For example, decisions about commencing an induction or a caesarean section appeared to be taken exclusively by the staff. 109 To highlight such coercion, McLeish109 cited a participant quotation:

When they wanted me to stay in hospital because of my high blood pressure I refused . . . I went home . . . They took me by force. They rang the police and told them to bring me back to the hospital.

Participant 5 staff109

When combined with the potential instability and uncertainty in some immigrant women’s lives, especially due to their immigration status and social circumstances, the participation of the health-care system in what appears to be violent and compulsory practices is concerning. Rather than taking sides, however, we see this participant’s perspective as crucial to spurring a reassessment of the practice of service and the challenges of properly communicating procedures and risks, especially within circumstances that may already be fraught with tension and mistrust of authority figures (which would include the NHS from the perspective of some of the mothers).

In cases when women did not have open communication with their midwives (e.g. feeling comfortable in disclosing their FGM), they were unable to share all their concerns and cultural needs. 117 Some immigrant women perceived their midwives to be cruel,108 and a woman in one study124 reported a very bad experience during labour. The midwife asked this woman to walk to the labour ward with her membranes ruptured, shouted at her during labour, refused to hold her hand and argued with the woman’s birthing partner about the practice of FGM.

During the postnatal phase some immigrant women reported that the midwives were angry with them when they approached midwives for help. 108 Midwives were also reported as being unkind, unfriendly and uncaring. 107 For example, an African immigrant woman complained that, after she had undergone a caesarean birth, the midwife did not look after her vomiting baby and left her alone at night. 107

Clearly, some women felt that their interactions with the midwives were devoid of cultural safety. These situations can occur when the demands of the system on the birth practitioners are translated by the women as culturally insensitive care:

I do not think the midwives were friendly with me. When I was delivering him, without my mum . . . I took one of their hands she said to me ‘Don’t touch me!’ I had to say to her ‘Sorry!’ . . . I thought she might hate me she might not help me.

Participant 1109

Although the study107 did not identify the maternity care setting clearly (such as antenatal, postnatal, or labour suites), the event was in a hospital setting. Furthermore, immigrant women feel midwives are too busy in hospitals and they lack support from midwives, particularly if the women had undergone caesarean deliveries. 107

Some women described experiencing more positive birth experiences in their countries of origin than in the UK. 123 This view often developed from poor treatment by midwives. However, this result conflicts with evidence we presented earlier that Middle Eastern women preferred UK birth experiences:

I am so disappointed that I delivered here, in spite of the midwife was nice, but she did not compensate for the general way [I was dealt with]. I maintain that delivery in Jordan is much better – there is no comparison . . . ‘Third World’, they empathise . . . here the indifference is perceptible.

Participant, Rahma. 123

Reproduced with permission from De Montfort University

Some women felt that community midwife visits were too short and were not helpful or congruent with the level of support they needed. 139 These women also expressed that the midwives engaged in poor communication, although the study did not explain how this poor communication manifested. 139 By contrast, a few women from the same study thought that their community midwives were most helpful and that the midwives offered them and their babies optimal maternity care and clinical support. 139 Instances of positive relationships with midwives postnatally also included new mothers reporting ‘very good’ support and education on baby care. 139

Immigrant women from the asylum-seeking category felt that midwives did not know their difficulties and never asked them about their immigration status. 118 The midwives also did not take into account their poverty and living conditions when giving maternity advice; therefore, such advice was not helpful for these women because it was not tailored to their specific situation. 118

Factors promoting satisfactory and positive relationships

When the midwives and immigrant women reported an open, comfortable and safe relationship, the women were able to discuss sensitive issues such as FGM,139 asylum-seeking and parenting. 137 Awareness of the immigrant women’s religion and culture played an important role for the midwives in developing positive relationships. 117 It indicated a high level of cultural sensitivity55,65,149 and an appropriate regard for the cultural safety51 of the immigrant women. The analysis identified positive examples of midwives who offered wider treatment options to immigrant women as a matter of course, and showed respect for their cultural and religious needs. In a study108 based in West London, the participating women reported that they had received helpful information on pregnancy and labour from their midwives. In a qualitative study,107 mothers also reported positive and trusting relationships with their midwives during labour and postnatally. Factors that strengthened a trusting relationship with the midwives and increased the quality of communication included maintaining a continuous presence during labour (which was seen as a comfort for the women) and keeping the husband fully informed and aware of the situation.

In some instances, midwives intervened to improve the living circumstances and the access to benefits of asylum-seeking women by referring them to the appropriate services. For example, one study118 reported how a midwife supported an asylum-seeking woman by writing a letter to the Home Office to prevent her dispersal (forced relocation to another area). Another community midwife helped an asylum-seeking woman to get her benefits, and a community midwife visited a woman on the postnatal ward to provide additional support to reduce her isolation and loneliness. In this same study, immigrant women felt that more time and attention, rather than less, was needed from the midwives during the postnatal period, because they lacked sufficient energy and resources to look after their baby properly after giving birth. 139

Rather than receiving ‘orders’ from midwives, the women understandably wanted to be actively involved, have choices and receive explanations of procedures:

She [the midwife] was asking me, ‘Why do you want this medication? You have a sour stomach now?’ . . . the doctor always gives me Zantac with any medication. If you are not convinced, call the doctor. But she would not listen to me.

Participant xyz123

Improved staffing levels on the postnatal ward (a universal theme) were needed to improve the quality and experience of care. 107 Although women preferred early discharge, they expected that the postnatal home midwifery care would replicate the care offered in a hospital setting. 110

Relationships with general practitioners and medical staff

Some findings related to the relationships between immigrant women and GPs and other medical staff. Immigrant women complained that often they were not treated with respect and sometimes misunderstood communications articulated by medical staff. 133 Some immigrant women reported experiencing aggressive behaviour from health professionals (unspecified), and one service user even reported a breach of confidentiality by her GP who was also a family friend. 126 Some immigrant women reported a lack of communication from doctors. 139 Overall, GPs were perceived to have a minimal role to play in antenatal care, which reflects the midwifery-led UK model of maternity care. However, this lack of medical input may contrast with the care women received in their country of origin. 111

Evidence of negative relationships was found when doctors did not explain to the immigrant women why they would not get the medicines they were normally prescribed for minor illnesses. 124 The studies highlighted differences in prescribing practices between the UK and the immigrant women’s countries of origin that led to unmet expectations. This negative perception was attributed to the UK emphasis on ‘self-management’ and ‘over-the-counter’ medicines, rather than prescribed remedies, for treating minor illnesses when compared with countries such as Pakistan127 and South Korea. 124 Consequently, the immigrant women reported feelings of insecurity and perceived that this lack of medical treatment might increase their risk of complications during their pregnancy. 124

Some immigrant women experienced racism or stereotypical comments and attitudes from some medical staff. 107 One study that provided an example of a racist attitude included the use of the term ‘Asian woman syndrome’, suggesting that the professionals perceived that women from an Asian background commonly exaggerated their symptoms and complained too much about minor illnesses. 121 These cultural assumptions were expressed in ways that the mothers felt were not only unprofessional but also may have jeopardised their care. Evidence arising from one study suggests that the negative attitudes and behaviour of some but not all GPs resulted in poorer access to care for the immigrant women and non-adherence to health-care advice. 111 In some cases, women (in this case Muslim women) would compromise on their cultural needs to avoid insensitive treatment from maternity care professionals:121

When I was referred, I was given the choice of a woman consultant, but the woman consultant is a nightmare. She’s really, really insensitive, so I chose to be referred to the man because of the insensitivity of the female.

Participant xyz. 121

Reproduced with permission from Nasreen Ali

Relationships with health-care professionals

Under this subtheme, we present findings from studies that used the terms HCPs or maternity care providers, but did not make clear which professional group they studied. Health visitors are included here because they are registered nurses or midwives who have undergone further training and gained additional qualifications.

The findings highlighted the relationships between immigrant women and health visitors and the ways in which these relationships affected care. Health visitors were reported by some women to be the best professionals they saw in the community setting, these professionals were keen to help the women and provided health-care support, emotional support and childcare needs. However, other immigrant women reported superficial engagement and a lack of thoroughness by health visitors who, for example, failed to explore their postnatal mental health in sufficient depth. 126

The women from the asylum-seeking category perceived feeling ‘labelled’ as asylum seekers and consequently felt that they experienced poorer and different care. In one instance, staff made assumptions about the woman’s health-care needs, such as undertaking a vaginal scan and asking her, unprompted, if she would like to terminate the pregnancy:118

They do me . . . vaginal scan? To check the baby . . . They ask me again if you want to take out the baby?

Participant 5118

The asylum-seeking women were distressed by being treated differently when accessing care. For example, a receptionist in a walk-in clinic shouted at a woman when asking her to provide her passport. Another woman had a negative experience when she encountered a receptionist who made derogatory comments about her non-working status, demonstrating her ignorance of the ineligibility for employment of asylum-seeking women:118

To register in our nearest GP . . . reception ask us . . . You have to bring . . . bills. And I told her, we don’t have bills ‘So you’re not working?’ . . . And I feel like! . . . I’m forbidden to . . . I feel . . . very bad.

Participant 5118

The immigrant women noted both subtle and direct forms of discrimination from the staff. 121 Subtle discrimination was by non-verbal communication and by addressing immigrant women’s requests and questions in angry and inappropriate ways. Direct discrimination included unfair, racist and stereotypical comments and assumptions being made based on a woman’s perceived cultural background:

I saw a consultant . . . She was not nice. She was very abrupt. ‘Did you circumcise?’ . . . I didn’t know women can be circumcised! ‘I’m asking you, are you circumcised?’ I don’t understand.

Participant 3118

No one offered me any antenatal classes . . . Nobody mentioned it to me . . . I really wanted to go but they [health professionals] don’t mention it to you. That’s the thing . . . [They think] Asian people don’t want to come to these antenatal classes.

Participant xyz. 121

Reproduced with permission from Nasreen Ali

Some professionals were found to be stereotyping immigrant African women as having an abnormally high pain threshold. 20 The stereotypes held by professionals on pain negatively affected the care received by the immigrant women, who perceived that they were not offered timely and sufficient pain relief. Some women also complained about a lack of emotional involvement by the HCPs. 123 That lack, together with discrimination, was felt to impair them from providing proper explanations and committing to shared decision-making during the care of immigrant women. 3,110

One study139 noted that a few immigrant European and Middle Eastern women felt that the professionals at the hospitals were easily accessible to them all the time, and they could ask them for prompt explanations and information at ‘the press of a button’:

If I ask them about something, they always told me what to do and they show me how to do this . . . Actually, they were everywhere, so it was easier for me to ask . . . if I press the button. They came to check what is wrong. 139

Reproduced with permission from University of Aberdeen

The women from European and Middle Eastern backgrounds also perceived community HCPs to be accessible, including by telephone. Some women were less satisfied with the telephone contacts because of their limited English-language skills. 139 Even though language was a barrier,108 the immigrant women in the asylum-seeking and refugees categories in many instances felt welcomed by ‘the staff’,110 cared for,122 and offered good service coupled with high attention, consideration123 and equal care. 139

The findings identified a lack of trust between maternity care providers and some immigrant women, especially on the need for caesarean section as a mode of delivery. 107 Mistrust between the maternity care professionals and the immigrant women can negatively affect the ability of the professionals to provide the expected quality in service. 113 If sufficient mistrust exists between the professionals and the immigrant women, some of the women might get their maternity care outside the UK. 4

To improve these relationships, the immigrant women highlighted that empathy and culturally congruent care from the professionals would help them to feel more positive about their experience of maternity care. 111 For some immigrant women, employing maternity care professionals of similar ethnocultural origin was important in building trust and enhancing communication. An alternative view argued that qualities such as being respectful and professional were more important than ethnocultural similarity. 113

Conclusion

This theme identified that positive relationships between immigrant women and maternity HCPs was critical in the access to and uptake of maternity care. Multiple factors influenced these relationships positively or negatively. Being respectful, caring and professional were key dimensions in developing positive relationships with immigrant women and these positive dimensions are reported in a number of studies. Conversely, stereotyping, racism and disrespect from maternity care professionals discouraged immigrant women from obtaining equitable access to the services and impeded adherence to professional advice.

Gaps in the evidence

Studies using social and psychological theories of ‘otherness’ and ‘difference’ are needed to more completely address the factors associated with negative and positive relationships between HCPs and immigrant women. Additional studies are needed, emphasising the structural dynamics within health systems that may encourage negative relationships between service users and health professionals.

Impacts of language and communication barriers to access and utilisation of maternity care

The findings indicated that some immigrant women were able to neither speak nor write in English. 132 Women with limited levels of English-language proficiency used gestures to express their needs:110

I waved my hands [to communicate].

Abeba, 2 weeks postnatal110

Lack of proficiency in understanding, speaking and reading English resulted in many challenges for immigrant women in maternity care services, including a limited awareness of available services, an inability to access services, an inability to articulate their health and maternity needs to service providers, and an inability to be understood by HCPs. Importantly, abuse and safeguarding issues may not be noticed without proper language support. These issues can be especially important in countries in which patriarchy is the cultural norm, such as India and Pakistan. One study3 reported the following situation from their sample:

One ‘No Recourse to Public Funds’ South Asian respondent, raped by her husband, told us she had wanted an abortion. However, her husband attended every appointment speaking directly with maternity professionals while clearly excluding her from decisions. She explained that she wanted an interpreter to report the abuse.

Phillimore3

Language fluency and communication play an important role in developing maternity care relationships. Lack of mutual understanding between immigrant women and HCPs led to visible frustration and anger on the part of the HCPs, hindering relationship development:113

The problem we Somalis have here as a refugee or as foreigners or as immigrants is the language . . . Everyone will be fed up with you if you can’t understand what they are saying – if you can’t talk to them . . . sometimes they will just ignore you.

Somali woman, informant 1113

Before they discharge me, the midwife came to me, my husband was there. She tried to explain a few things how to lie down the baby in bed and how to register his birth and how to look after the baby, how to feed him. But he didn’t understand.

Meena, 2 weeks postnatal110

Lack of speaking and understanding the English language often resulted in miscommunication between immigrant women and HCPs. 20 Often the immigrant women did not understand care procedures and their outcomes, discouraging them from fully taking advantage of maternity care services111 and negatively affecting their experience with the health professionals. 126

Language and communication barriers affected almost all phases of maternity care. In terms of antenatal care, language and communication barriers are cited as reasons for immigrant women booking late3 and therefore failing to access the recommended minimum number of antenatal appointments. 47 In a multivariable model of a quantitative study,14 the authors noted that the inability to speak English had an independent effect, increasing the late initiation of antenatal care among immigrant women [do not speak English and not born in the UK: n = 1060, odds ratio = 1.47 (95% confidence interval 1.23 to 1.76)]. 14 In another study, immigrant women wanted to attend parent education classes but did not because they were offered in only English. 20

Immigrant women with limited English-language proficiency felt both frightened107 and ignored by HCPs. 113 Consequently, the women developed the view that they were not being supported properly by HCPs and worried that they would develop complications in their pregnancies. 108 Limited language proficiency in some women hindered their involvement and decision-making regarding their care, specifically during delivery. 121 Often women gave consent for clinical procedures without fully understanding the explanations provided by the HCPs:20

How are they asking people if they do not even understand, you know? It is the matter of understanding . . . Most . . . don’t even understand the questions they are asking, so how do they expect them to, you know, give their consent for whatever is being done to them?

Participant xyz121

I was referred to another hospital, they did not advise why. At my third appointment, I had an interpreter. The whole process was rushed, I did not know what to expect. I did not feel involved in any of the decisions – someone else always made them for me.

Chinese, failed asylum seeker20

Limited English-language proficiency also limited the offers the immigrant women would receive for a wide range of available care options. Such women did not receive proper advice on baby care, including on immunisation139 and feeding their babies. 110 In one case, the communication barriers between HCPs and a service user resulted in the service user misunderstanding that formula milk was a better option for her baby than breastfeeding. 110 Immigrant women who experienced discontinuity in maternity care experienced more difficulties relating to communication. 108 However, some women or their partners were found to initiate communications in organising appointments and clarifying procedures in their care. 123 Poor communication between the women and HCPs sometimes occurred when the professionals noted a possible challenge in the pregnancy but did not share their concerns with the women. 111 Other manifestations of poor communication included the HCPs sometimes being discourteous, compassionless and abrupt. 111

The evidence indicates that the women regarded a reassuring and engaging type of communication as more effective. 111 Furthermore, women with low levels of English proficiency felt that receiving written information, such as a letter for referral, from the HCP was more helpful than receiving verbal information alone. 122 Similarly, careful listening to the concerns of the women and taking time to explain things also improved communication. 108

Interventions to reduce communication barriers that impair access and utilisation

The findings from this review identified three types of interventions to address the language and communication challenges, and to improve communication between HCPs and immigrant women: (1) formal interpreting services; (2) informal interpreting by family or friends; and (3) linkworker and advocate services.

Impacts of language and communication barriers on the provision of maternity care information

Immigrant women with limited proficiency in English are unable to benefit from written and spoken material on maternity care. 121 Translated content on maternity care is available only in the languages of established immigrant communities and new immigrants usually find such information inaccessible to them. 20 Consequently, many immigrant women with limited English-language proficiency were not knowledgeable about the systems and processes of maternity care services in the UK, the range of treatment options available to them, and their usual rights and entitlements. Therefore, these women were not well prepared for the birth of their babies. 121 Moreover, not all immigrant women receive maternity care information from health-care providers. For example, nearly half of the women sampled in one study20 did not receive dietary information. Consequently, immigrant women with limited proficiency in speaking or reading English have access to only those resources that are provided in their native language. 133 These women therefore depend on their ethnic peers to seek and provide them with information on maternity care, such as infant and maternal nutrition.

Interventions to reduce communication barriers that impair the provision of information

In the review, we found two types of interventions that have been implemented in the past: (1) provision of information in the appropriate ethnocultural languages and (2) provision of bilingual support workers.

Conclusion

This theme has identified that immigrant women with limited English-language skills experience communication barriers in accessing and utilising satisfactory maternity care in the UK. These barriers were persistently highlighted in the decades-long time frame covered in this review (1990–2017). However, very few interventions were found that focused on improving verbal and non-verbal communication between HCPs and the immigrant women accessing maternity care; and most were dated. Moreover, evidence on evaluating the effectiveness of these interventions was considered to be methodologically weak and dated, and these interventions may not be relevant for the super-diverse population currently accessing maternity care in the UK.

Gaps in the evidence

The intrapartum phase is a high-risk and critical time, but studies focusing on communication challenges and interventions in this phase are almost absent. Many of the existing studies in respect of communication were conducted several decades ago. In the current period of ethnocultural superdiversity in the UK, with many new and more diverse groups needing maternity care, more contemporary evidence is required. The system lacks comprehensive strategies, at scale, that consider interventions as part of an integrated system of maternal care.

Organisation of maternity care services and the experiences of immigrant women

The immigrant women in the studies we reviewed had mixed experiences in relation to the maternity care services they received in the UK. 127

Rights and entitlements for maternity care and the experiences of immigrant women

The rights and entitlements of immigrant women for maternity care in the UK had an important bearing on the experiences of women in accessing and utilising maternity care. The immigrant women without entitlement to free maternity care services in the UK were deterred by the charges and confidentiality of their legal status; hence, they did not access timely antenatal care. 47 Many women in the undocumented and asylum-seeking immigrant category missed their maternity services appointments, as they did not have recourse to public funds. 20

Asylum-seeking women were sometimes dispersed in the final phase of their pregnancy, which resulted in discontinuity in the care process and the loss of their social networks. 20 The dispersed women felt that they did not have any control or power over their lives. 20 The dispersal process, whether in early or late stages of pregnancy, was a main factor in increasing mental stress for pregnant asylum-seeking women.

Pregnant asylum-seeking women reported having to live in accommodation with other unknown asylum-seeking women. Living with other asylum seekers who had their own problems generated more stress and constituted an unsatisfactory environment for the pregnant asylum-seeking women:

If you live with . . . other women [who] are asylum seeker like us, and everyone have problems like stress . . . One is cleaning, one not. One is like, shouting, one is quiet. One is like . . . the TV loud . . . better to stay like, all by your own.

Participant x118

These negative views from asylum-seeking women were also supported by the views of HCPs in one study. 122 Maternity care was delivered to asylum seekers as per their health needs assessments, which gave priority to the views of HCPs rather than being a coproduction with asylum seekers. For example, one of the participants in the study noted the following:

It is not a service that is led by them [asylum seekers] . . . at all, it is a maternity-led service.

Participant M1122

The women in spousal migrant categories were also not entitled to public recourse for the first 24 months of their arrival in the UK and retained no right to live in the UK if their marriage was dissolved. Such women were specifically discouraged from reporting their personal health needs, particularly those arising from domestic violence. 20

Breastfeeding support from maternity services and the experiences of immigrant women

The findings have identified mixed experiences regarding support the women received from HCPs for breastfeeding their babies.

Reducing negative impacts

To address organisational and legal entitlement issues in accessing and utilising maternity care, evidence from earlier studies highlighted the need to establish maternity clinics locally, which reduces hospital travel times and minimises waiting times to see HCPs. 132 Evidence from this review suggests that immigrant women want to see their midwives as and when needed, even on the same day, and in some instances they also wished increased frequencies of scans and regular check-ups in the early stages of their pregnancies. 127

Many women in the asylum-seeking and refugee categories felt lonely and isolated, and they expressed a need for HCPs who could offer them the opportunity to talk, listen and understand their ideas and concerns. 110 They also wanted better opportunities to give feedback on the maternity care services they were offered. 136

To address poor care due to staff shortages, the women suggested that the maternity services should have policies and procedures to allow their husbands or partners to stay with them in the hospital so that they could assist with the support of the women after birth. 107 At the hospital, the women who had delivered by caesarean section wanted more help after the birth of their babies and wanted practical demonstrations on positioning the baby onto the breast for feeding. The evidence arising from the review indicated that supporting immigrant women with breastfeeding could be accomplished by integrating their health and social care and by involving experienced refugee mothers in the support of new ones. To offer continuity in maternity care, the evidence from the review highlighted the importance of having a named midwife for each immigrant woman. 121

Conclusion

The evidence from this review suggested that inflexibilities in the organisation of maternity care services in the UK affected its accessibility to and utilisation by immigrant women.

Gaps in the evidence

Most immigrant women come from countries where breastfeeding is a cultural norm, but it is not in the UK. We need more research on how to maintain existing breastfeeding practices, as the health benefits are substantial and they contribute to the health of the nation.

The impact of the limited legal rights on the health of the mother and infant requires further research.

Discrimination and racism

The findings identified that discriminatory treatment and care was received by some immigrant women from HCPs, during various phases of maternity. Discrimination in maternity care services mitigates the delivery of good-quality maternity care. 20 The discrimination was often subtle and difficult to specify, but direct and blatant discrimination was also experienced in some cases. 121 Subtle discrimination included the staff responding to women’s questions or requests in rigid and inappropriate manners. Evidence from one study reports that immigrant women were often not welcomed or greeted in a friendly manner and not made to feel safe. 3 Some women suffered acute negative feelings when they were seen and treated differently by maternity care staff. 118

Direct discrimination included health-care staff uttering stereotypical and racist comments:

I got an infection in my scar . . . I went to the midwife and said I’m feeling cold, and all my body shakes . . . She looked at me like this and said, ‘You are OK’. . . . She said to another midwife, ‘These Africans . . . they come here, they eat nice food, sleep in a nice bed . . . I just cried – she doesn’t know me, who I am in my country. The other midwife said ‘What’s wrong with them’ some of them laughed.

Participant 24109

Somali women are not into preventive medicine at all.

White British doctor 6112

Immigrant women from the Muslim faith criticised the assumption held by HCPs that their partners or husbands should collaborate with the women during labour. Study participants also challenged the assumptions of the HCPs around their food practices. Sometimes other immigrant women are accused of overusing maternity services as a result of exaggerating symptoms, an accusation that is called the ‘Asian woman syndrome’:121

They [health professionals] should not make the assumption that they [Muslim men] are going to be present at the birth. My husband was not there, I didn’t want him there. My mother was there. 121

Why do they assume that all Muslims want to eat curry? You ask for a halal meal, they will send you a curry. Maybe not everybody likes a curry. There are Chinese Muslims, there are Caucasian Muslims, you know? Muslims from all over. 121

Several women talked about staff belittling their worries and concerns, implying they were exaggerating symptoms, wasting time or complaining about ‘minor’ problems in order to get help. The women said staff often referred to this as ‘Asian woman syndrome’. 121

I have had doctors who tell me to have a coil put in after I have had the baby . . . and when I say I want to carry on having babies, he said, ‘You want to receive more benefits. That’s why you are having more babies’. 121

Reproduced with permission from Nasreen Ali

Similarly, women from an African background reported being stereotyped as having high pain thresholds and long labours; hence, they were not given timely or adequate pain relief. 20 Other examples of labelling and assumptions being made based on a woman’s perceived cultural background were also found:

I saw a consultant . . . She was not nice. She was very abrupt. ‘Did you circumcise?’ . . . I didn’t know women can be circumcised! ‘I’m asking you. Are you circumcised?’ I don’t understand.

Participant 3118

They do me . . . vaginal scan? To check the baby . . . They ask me again if you want to take out the baby?

Participant 5118

Some women felt labelled as an asylum seeker, with staff making assumptions about their needs. In one case, this meant a presumed need to terminate the pregnancy. 118

Similarly, a GP is reported in another study to have expressed the view that offering counselling services to asylum-seeking women did not fit with their needs because it was a ‘very Western concept’. 122

Immigrant women from a Muslim faith noted increases in discrimination and were viewed as a different and dangerous people. 121 However, this evidence was from one small study identified in the grey literature. 121

The findings highlighted perceived racism in maternity care when immigrant women from specific countries were advised by HCPs to undertake a specific medical intervention owing to their national origin or race:

They targeted me and my baby as high risk for TB [tuberculosis] and offered the BCG [Bacillus Calmette–Guérin] vaccine . . . a difficult decision to make after giving birth. Singled out because Chinese . . . I am very upset by this and my baby has a huge scar! It was pure racism in my mind.

Chinese woman, non-UK born107

Disrespect, inaction and lack of attention

Findings from one study suggest that participants perceived that the staff did not treat them as human beings with due respect and full attention. 109 Because of this lack of respect from HCPs, the women felt devalued, unsupported and fearful when receiving maternity care. Such findings were reported in antenatal, intrapartum and postnatal care settings:

I feel I am treated like the air.

Participant 13109

I am rubbish. I haven’t got anything left. I have no value. I pretend too much to be happy but inside me I am dead.

Participant 6109

I couldn’t move or breast feed the baby, but they did not help me . . . only if I asked . . . When they sent me to the postnatal . . . my baby choked started frothing at the mouth. I rang the bell more than once until they came. I said, ‘Look at baby! I can’t move’.

Participant Fatima. 123

Reproduced with permission from De Montfort University

I went to the hospital they let me wait . . . Then they examined me. I was in pain no one came and talked with us. They only said to wait . . . I told my husband. ‘I can’t stand it anymore. Go and talk with them’ . . . They said, ‘Sorry, we are coming’.

Participant xyz. 123

Reproduced with permission from De Montfort University

Some of the midwives spoke to me very arrogantly. Sometimes I got scared as I don’t know the English language very well. It would be very nice if they gave you a smile now and then. Also, it would be nice if they didn’t give orders.

Pakistani woman, non-UK born107

Culturally sensitive maternity care

The evidence in the review noted a prevalence of anxiety about childbirth among the immigrant women in the UK. 123 This was expressed by a participant in the study as follows:

They do not stitch you up after delivery, nor do they perform any cosmetic suturing; I don’t know if this is true or not . . . The second concern is that I heard that they do not give a woman any anaesthetic during delivery, which worries me a lot.

Participant Rahma123

The findings indicate a lack of cultural sensitivity and cultural understanding among HCPs working in maternity care, thus resulting in culturally insensitive care for immigrant women. 121 The findings indicated that immigrant women of the Muslim faith did not optimally benefit from antenatal classes because they were delivered by non-Muslim educators who were not knowledgeable about the Islamic faith related to maternity. In addition, the sessions were with men and women and included other ethnic and religious backgrounds:121

They [women in Muslim-only antenatal classes] would be able to ask and people would understand about religion, like needing a female doctor . . .

Participant xyz. 121

Reproduced with permission from Nasreen Ali

A participant highlighted the lack of cultural knowledge and cultural sensitivity of the staff during the intrapartum phase:

I had a full circumcision, but basically there was no one who had the experience to deliver the baby, so they had to call someone from another hospital. He was a Sudanese man, so I had to have a male doctor to deliver the baby because there was no one else.

Participant xyz. 121

Reproduced with permission from Nasreen Ali

Some immigrant women of Muslim faith felt that the maternity care services were unable to understand and meet their cultural and religious needs on the postnatal wards for breastfeeding:121

I wanted the privacy. The dads are there . . . I just wanted to be able to have privacy to breastfeed without people walking around, because I wear hijab as well. The English women, or the non-Muslim women, are happy to breastfeed openly . . . I didn’t want that.

Participant xyz. 121

Reproduced with permission from Nasreen Ali

Similarly, in another case, an immigrant woman (whose faith was not indicated) complained as follows:

. . . [she had] asked for placenta for religious condition to be buried, but it was taken away.

Indian woman, non-UK born107

Another cultural condition that the immigrant women felt that the staff lacked understanding about and proper responses to FGM. 108

In addition to the staff’s lack of cultural understanding, maternity care services, as a whole, were reported as not meeting the cultural needs of immigrant women:121

I don’t even allow my husband to be in the labour room . . . because I feel uncomfortable with men . . . Even he [my husband] refused to come in. 121

The views held by immigrant women about culturally insensitive maternity care was endorsed by maternity HCPs, as noted by a study in the West Midlands:20

I don’t think the system works well at all. It’s terrible and it’s geared up for white middle-class women.

Midwife, Birmingham20

By contrast, the findings also noted that in a few cases the midwives were happy to meet the cultural and religious needs of the immigrant women in antenatal and postnatal settings. 121 For example, by acting proactively, a midwife was able to discuss the cultural and religious needs of an immigrant woman. When a Muslim woman asked the midwife to sweeten her new baby’s mouth with a date or honey (an Islamic custom), the midwife happily did:121

The midwives were happy to do that, she said, ‘Whatever you have to do’, so they were quite sensitive. They know what we had to do. 121

Cultural clash and conflicting medical advice

The findings identified instances of cultural clash and conflicting advice during pregnancy and maternity care. 123 Cultural clash and conflicting medical advice resulted because cultural practices and the established medical and maternity care systems differ in the UK from those in the home countries of the participants:

I came here in October, and in January I was pregnant. During that time, I spoke to my doctor in my own country. I don’t want to be confused between [the advice I was getting from the] two doctors, so I am not following [the doctor’s advice] here.

Participant xyz. 123

Reproduced with permission from De Montfort University

During this pregnancy, my mother was with me and she always reminded me that I was pregnant . . . In my country there is a list of forbidden things.

Zahra. 123

Reproduced with permission from De Montfort University

On the first visit, the midwife told me, ‘You are not sick, you are pregnant’. In Egypt, they let you feel that you are sick and that this is abnormal, which is why they pay more attention to it.

Participant xyz. 123

Reproduced with permission from De Montfort University

Conclusion

This theme presented evidence that immigrant women were often the subject of discrimination and stereotyping and were offered poor maternity care in the UK. Some maternity care services and staff lacked cultural sensitivity when delivering care to immigrant women. Discrimination and cultural insensitivity in maternity care services contributed to the generation of inequalities in access, utilisation and outcomes for immigrant women in maternity care.

Gaps in the evidence

No intervention was reported that focused on addressing discrimination, stereotyping, racism or cultural insensitivity to improve maternity care for immigrant women.

Summary of findings

Our themes were as follows:

1. access and utilisation of maternity care services by immigrant women

2. maternity care relationships between immigrant women and health-care professionals

3. communication challenges experienced by immigrant women in maternity care

4. organisation of maternity care, legal entitlements and their impact on the maternity care experiences of immigrant women

5. discrimination, racism, stereotyping, cultural sensitivity, inaction and cultural clash in maternity care for immigrant women.

Our review established strong and robust evidence for three themes presented above (themes 1, 2 and 3).

Although we found evidence to support our theme development for themes 4 and 5, the evidence was less comprehensive. Nevertheless, themes 4 and 5 highlight important critical dimensions of care. Please see Appendix 6 for an overview of the studies supporting each theme.

Theme 1: access and utilisation of maternity care services by immigrant women

Late booking emerged as an important dimension in this theme, that is that immigrant women study participants tended to book and access antenatal care later than the recommended time frame (during the first 10 weeks of pregnancy). This issue was found to be multifactorial in nature, including issues such as limited English-language proficiency, immigration status, lack of awareness of the services, lack of understanding of the purpose of the services, income barriers, the presence of FGM, differences between the maternity care systems of their countries of origin and the UK, arrival in the UK late in the pregnancy, frequent relocations after arrival, the poor reputations of antenatal services in specific communities and perceptions of regarding antenatal care as a facet of medicalisation of childbirth. The factors affecting the access and utilisation of postnatal services were similar to those reported for antenatal services.

Theme 2: maternity care relationships between immigrant women and health-care professionals

Our included studies evidenced the perception of service users in this group and their interactions and therapeutic encounters with HCPs. These interactions were significant in understanding access, utilisation, outcomes and the quality of their maternity care experience.

Included studies in this theme demonstrated that the perceptions of study participants regarding the ways in which HCPs delivered maternity care services were both positive and negative. A number of studies illustrated positive relationships between HCPs and immigrant women. Study participants asserted that the HCPs were caring, respected confidentiality and communicated openly in meeting their medical, as well as emotional, psychological and social, needs. Conversely, studies showed evidence of negative relationships between participants and HCPs. Studies showed HCPs, from the perspective of immigrants, as being rude, discriminatory, or insensitive to the cultural and social needs of the women. Consequently, women tended to avoid accessing/utilising maternity care services consistently.

In our included studies, participants expressed a desire for the HCPs to be empathetic, respectful, culturally congruent and professional when providing maternity care services. Some women also suggested employing HCPs from the immigrant population.

Theme 3: communication challenges experienced by immigrant women in maternity care

It is axiomatic that limited English-language fluency presents verbal communication challenges between the HCPs and their patients, families and carers. Moreover, this is compounded when HCPs use complex medical or professional language that is difficult to comprehend. Non-verbal communication is culturally defined and challenges can occur through misunderstandings of facial expressions, gestures or pictorial representations. Our evidence shows that poor communications result in limited awareness of available services. Communication challenges also create miscommunication with HCPs. Study participants often expressed challenges accessing services; failed to understand procedures and their outcomes; were constrained in their ability to articulate their health or maternity needs to health-care providers; were disempowered in respect of their involvement in decision-making; often gave consent for clinical procedures without fully comprehending the risks and benefits; and did not receive understandable advice on baby care. Studies identified that communication was not reciprocal and HCPs often misunderstood participants. This created feelings of isolation, fear and a perception of being ignored. Interventions to address the language challenges included the provision of formal and informal services, bilingual support workers and written maternity care information in the necessary languages.

Theme 4: organisation of maternity care, legal entitlements and their impact on the maternity care experiences of immigrant women

The legal status of immigrant women in the UK has a profound influence on their access to maternity care. Women without entitlement to free maternity care services in the UK were deterred from accessing timely antenatal care by the costs and by the confidentiality of their legal status. Moreover, some women arrived in the UK during the final phase of their pregnancies, which resulted in fractures in the care process, loss of their social networks, reduced control over their lives, increased mental stress and increased vulnerability to domestic violence.

The study participants in our included studies had mixed experiences with the maternity care services in the UK. Positive and commendable experiences included feeling safe in giving birth at a hospital, rather than at home; being able to register a complaint if poor health care was received; being close to a hospital facility; not being denied access to a maternity service; and having good experiences with postnatal care. Conversely, negative experiences included lack of continuity (e.g. not being able to see the same maternity care providers each time and being unaware of the configuration of maternity services work, limiting navigation). Participants in our included studies found services within the UK maternity care model to be bureaucratic, and perceived a propensity towards medical and obstetric intervention and lower segment caesarean section births.

Positive experiences included receiving information from their midwives on the benefits of breastfeeding, together with demonstrations on how to position the baby. Negative experiences included poor support from hospital staff on how to breastfeed their babies. Consequently, these reported experiences are mixed.

Theme 5: discrimination, racism, stereotyping, cultural sensitivity, inaction and cultural clash in maternity care for immigrant women

Inequalities in access, navigation, utilisation and the subsequent maternity care outcomes are influenced by discrimination and cultural insensitivity in maternity care services, according to the perspectives established in our included studies. Discrimination was often subtle and difficult to identify, but direct and overt discrimination was reported in some studies. The findings informing this theme arise from 12 of the 40 included studies.

Specifically, study participants of Muslim faiths challenged assumptions held by HCPs, including those held regarding Muslim food practices and that their partners or husbands should help the women during labour. In addition, evidence from our included studies suggested that they also felt that they were regarded as different and dangerous people. Moreover, HCPs were reported in some studies to lack cultural sensitivity and cultural understanding. For example, these women did not optimally benefit from antenatal classes facilitated by a non-Muslim educator who had no knowledge of the relationships of Muslim culture to maternity. Furthermore, studies reported participant dissatisfaction of antenatal classes with a gender mix, which contravened religious edicts. Studies illustrated that some women of Muslim faith felt that their cultural and religious needs for breastfeeding were not met on the postnatal wards and they felt that the staff lacked insight, knowledge and understanding of FGM.

Evidence from our included studies suggest that immigrant women perceived that the staff did not treat them with respect or full attention. They felt devalued, unsupported and fearful when receiving maternity care. In a few cases, however, midwives were happy to meet the cultural and religious needs of the study participants in our included studies, in both antenatal and postnatal settings; this is a positive finding.

Our findings also identified instances of cultural clash and conflicting advice during pregnancy and maternity care, mostly resulting from differences between the home countries of the immigrants and the UK in their cultural practices and medical systems.

A theory or model is a postulation of reality and provides a systematic and logical explanation for the meta-inferences and observed phenomena in our included studies. We present a conceptual model of our findings, embedding the key drivers and influences. These key drivers and influences form the critical domains or foci that require interventions and service enhancement to enhance the maternity care experiences of women in the UK maternity care services. Policy and practice development focusing on these domains can therefore bring about benefits and enhancements to maternity care (Figure 9).

FIGURE 9.

Maternity care experiences of immigrant women. Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Reproduced from Higginbottom et al. 24 © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

Policy context

Maternity services are essentially public health services that play an important role in improving health and reducing inequalities. Recently policy recommendations that call for modernisation of maternity service, for example National Maternity Review. Better Births; Improving Outcomes of Maternity Services in England,6 A Maternity Strategy for Northern Ireland 2012–2018,158 Refreshed Framework for Maternity Care in Scotland159 and A Strategic Vision for Maternity Services in Wales. 160 The overall vision for the maternity services in the UK is to improve the safety and quality of maternity care. National Maternity Review. Better Births; Improving Outcomes of Maternity Services in England6 set out a 5-year vision for improving the quality of maternity care, providing women and newborn infants with safer, more personalised, kinder, more professional and more-family friendly care, ‘where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances’ (contains public sector information licensed under the Open Government Licence v3.0). 6 These goals and aspirations match many of the concerns identified by women in our included studies.

The premise behind this vision in the UK is that the services should be flexible and individualised, designed to fit around the needs of the woman and newborn infant, and her family’s journey through pregnancy, childbirth and parenthood. Women and their partners should be supported and encouraged to have as normal a pregnancy and birth as possible. This ambition with regard to the provision of individualised care intersects very well with the findings of this review in respect of immigrant women and maternity care services.

Safety features throughout the Maternity Transformation Programme (this programme is responsible for achieving the vision set out in Better Births) aims to drive improvement in maternity services. Likewise, proposals in the government’s Safer Maternity Care: Next Steps Towards the National Maternity Ambition146 focus on five key drivers for delivering safer maternity care, which are ‘leadership’, ‘learning and best practice’, ‘multi-professional team working’, ‘intelligent use of data’ and ‘innovation’.

Consideration might be given to maternity services improving interagency arrangements (through clinical and local social services networks), including protocols for information sharing and a lead professional, to ensure that women from disadvantaged groups have adequate support and benefit from other agencies (such as housing), referring women, with consent, to local maternity services.

Our findings highlight the criticality that interpreting services are provided for women for whom English is not their first language. Relatives should not act as interpreters. It is paramount in terms of addressing inequalities that funding must be made available for interpreting services in the community, especially in emergency or acute situations.

Successfully providing appropriate maternity care requires the legitimisation and incorporation of the pervasive traditional beliefs and practices of immigrant women, to which these women often adhere despite their new milieu. Their beliefs on maternity care may differ considerably from Western biomedical perspectives. However, a recognition is required that beliefs may change over time due to acculturation. Care provision based on a rigid perception of ethnocultural orientation may lead to stereotyping, and therefore a nuanced strategy of care is required. Overcoming migration issues and language barriers will also be a major factor.

In a diverse pluralistic society, maternity service, care provision and delivery to immigrant women should be everyone’s business. Consideration to addressing the findings from this review might be addressed via the following mechanisms, as articulated in the Transforming Maternity Care programme.

Decision-makers and health-care leaders should address the findings at a strategic level. A focus on diversity, equality and the needs of immigrant women could reasonably be embedded in the role and responsibility of ‘board-level maternity champions’ and of ‘maternity clinical networks’. Maternity service providers could consider the appointment of one obstetrician and one midwife jointly responsible for championing maternity care provision to immigrant women in their organisation, as these dimensions feature in the bespoke maternity safety improvement plan. 161

Key areas of action include:

• focus on learning and best practice, issues of equality and diversity should be featured in the saving babies’ lives care bundle for use by maternity commissioners and providers

• focus on multiprofessional team working, continuous personal and professional training

• focus on data, greater focus on ethnicity and immigration within the maternity services data set and other key data sets

• focus on innovation, create space for accelerated improvement and innovation at local level.

In Table 5 we provide a summary of the review implications, illustrating their relationship to the review themes and the underpinning evidence from the review.

What is the value of this synthesis for the education and training of health-care professionals?

To improve maternity care experiences for immigrant women, we need to improve these women’s access to the services and increase the acceptability of these services. We suggest that the education and training of HCPs needs to take into account the dimensions shown in Box 7, both in the core education programme and in ongoing professional development.

The reality of the UK context as a super-diverse society demands health-care providers who are culturally competent and culturally safe so that they will be able to communicate effectively with immigrant women and their families. The goal is the delivery of high-quality maternity care for immigrant women who are from diverse sociocultural, economic and environmental backgrounds and provide them with quality health care. 164 A number of different definitions, typologies and models have evolved55 to assist in the identification of the key components of culturally safe and competent care as well as ways in which practitioners and organisations can enhance their performance and delivery of care in this area. Prior to embarking on a learning path to develop skills in culturally safe and competent care provision, a theoretical grounding is imperative. Moreover, cultural safety and competence improves patient satisfaction, as many ethnocultural groups value relational quality (as established in this review) and the resultant individualised care.

We suggest that a focus on cultural safety and competence could provide vehicles and mechanisms for improving maternity care services for immigrant women in the UK.

Gaps in the evidence in this review

In the current period of superdiversity in the UK, more contemporary evidence is required. We need complete strategies, at scale, that see interventions as part of an integrated system of approaches and care. In concluding, and as noted earlier, studies are lacking on interventions and their effectiveness in enhancing accessibility and utilisation of maternity care for immigrant women. Studies addressing factors associated with negative and positive relationships between HCPs and immigrant women using social and psychological theories of ‘otherness’ and ‘difference’ are also needed.

Intrapartum/delivery is high risk and is a critical phase of maternity, but studies focusing on communication challenges and interventions are almost absent. Many of the existing studies on such communication were conducted several decades ago. Most immigrant women come from countries in which breastfeeding is a cultural norm, but it is not in the UK. Therefore, more research is needed on how to maintain their existing breastfeeding practices, as the health benefits are substantial and contribute to the health of the nation. For asylum-seeking mothers, the impact of limited legal rights on the health of the mother and infant also needs more study. No intervention has been reported that focuses on addressing discrimination and stereotyping, eradicating racism and reducing cultural insensitivity to improve maternity care for immigrant women.

Additionally, the structural dynamics within health systems have not been emphasised as yet, even though they may encourage or even foster negative relationships between service users and HCPs.

Who should know the implications?

The target list includes policy-makers, commissioners, women in communities, academics, midwives, clinical trainers, HCPs, maternity action groups, migrant women’s rights services, GPs, students in health-care programmes, volunteer and community services organisations, organisations working with migrant women, maternity voice partnerships, the Department of Health and Social Care, UK Visas and Immigration, the Royal College of Midwives, the Royal College of Nursing, Public Health England, the World Health Organization, support agencies in other countries, migrant refugee organisations, religious leaders, local councils, pressure groups, Unite Community Practitioners and Health Visitors Association and, indeed, everyone.

Activities undertaken

• Publication of the review protocol.

• National research symposium with key stakeholders.

• Oral presentation at the Healthy Mothers and Babies Conference, Vancouver, Canada, 1 March 2018.

• Oral presentation to GPs and primary care nurses at the Academic Unit of Primary Care, University of Sheffield, Sheffield, UK, 19 September 2018.

Further activities

Publication of the findings paper in an academic journal. Contributions to theory and practice will occur via publication of findings in high-impact international journals, such as the Journal of Immigrant and Minority Health, Sociology of Health and Illness, Journal of Health Services Research and Policy and Social Science and Medicine, as well as open-access journals such as BMC Pregnancy and Childbirth and BMJ Open Access. The PAG will be invited as co-authors.

Knowledge translation and impact

GH is invited to participate in a multidisciplinary, international Delphi Expert Panel that will select a core set of validated items that can measure mistreatment in medium and high resource countries and align with the World Health Organization Quality of Maternal and Newborn Care framework.

Supported by the Canadian Institutes of Health Research 5-year grant we will study respectful maternity care and mistreatment of pregnant families across Canada, using a participatory research methodology.

GH is invited to participate as an external (independent) International Advisory Group member for the recently funded NIHR Research Global Health Research Group on Preterm Birth, University of Sheffield, along with PAG member Dr Caroline Mitchell. Principal investigator Professor Dilly Anumba. Funding: £2M. Capacity building has resulted from this review as CM (PAG member) is leading the knowledge synthesis strand of this significant study.

GH is invited to provide a methodological workshop on NS at the University of Middlesex on the 16 October 2018.

Migrant maternity and infant mortality in the West Midlands

Perinatal mortality rates in wards with large concentrations of migrants exceed the regional average, with the most deprived super-diverse wards housing large proportions of migrant women being among the highest in the UK (17 per 1000 vs. 7.6 per 1000 for England and Wales).

Initial booking

Some 82% of respondents (n = 67) accessed some kind of service when < 12 weeks pregnant. Nine (11%) respondents attended between 12 and 16 weeks, two (2%) respondents between 17 and 20 weeks, one respondent between 21 and 30 weeks and three (4%) respondents after 31 weeks. Late bookers tended to be asylum seekers, refugees and spousal migrants. The first services accessed were the GP (n = 56), referral to a midwife for nutrition advice (n = 53) or being offered advice about antenatal tests (n = 47). Some 53 women had antenatal tests before 12 weeks, whereas 15 women did not. Women booked late for a range of reasons, including not having sufficient information about services (n = 8), not understanding the services available (n = 5), lack of translated materials (n = 4) lack of an interpreter (n = 4) or not being registered with a GP (n = 2). For example, a Chinese refugee in Birmingham wanted to register her pregnancy but did not know who to contact, ‘. . . my friend told me who to first contact. It is different to China where all health-related services take place in a hospital’. Respondents who had received advice about how to access maternity services gained information from a community midwife (n = 46), GP (n = 31), family and friends (n = 8) or community organisation (n = 7). Basic information about procedures and routines was not readily available to migrant women and rarely translated into new migrant languages. One refugee did not understand why she was told to have a blood test and sought advice via transnational networks. Several women respondents could not find information about maintaining a healthy pregnancy and sought such help from friends and family. Lack of knowledge about pregnancy monitoring processes left women fearful of scans and tests, and unsure whether or not they should consent to procedures. Women with immigration problems told how they worried that they would be tracked by immigration authorities and their babies removed if they registered with maternity services believing their presence in the UK would be evident if their name was entered into an electronic database. Indeed, a small number of women respondents felt unable to share their anxieties with their midwife, as the professionals seemed rushed. Family members were frequently used for interpretation, but such practice often excluded women from conversations about their care, a situation repeatedly raised as a concern by women.

Follow on

Having made initial contact with maternity services some 65 women (80%) were able to attend all the appointments they were offered, whereas 16 (20%) were not. Reasons women gave for non-attendance included no transport (n = 11) or inability to afford transport (n = 8), not being well (n = 6), inability to communicate (n = 3), dispersal (n = 2) or domestic responsibilities (n = 2). All but two respondents in the rural areas attended their appointments, whereas attendance in urban areas was patchier, with between one-third and all respondents in the different cities not attending follow-ups. A8 migrants were most likely to attend (94%), whereas 50% of South Asian respondents and two-thirds of African respondents attended. Failed asylum seekers, NRPF and spousal migrants were the least likely to attend all follow-up appointments. Some failed asylum seekers in the UK receive Section 4 support, set at 60% of income support levels, which themselves are already acknowledged to be too low to keep recipients above poverty lines. Section 4 payments are made via the Azure card and previously by vouchers which could only be used in certain shops. Respondents had no flexibility and choice, were unable to use cheaper shops and markets and could not travel. Some failed asylum seekers and irregular migrants with NRPF are not permitted to work; therefore, they had no income whatsoever and depended on friends for food and/or cash for travel. Women on low incomes could reclaim the costs of travelling to appointments, but claims could only be made retrospectively. Respondents were unaware of the possibility of reclaiming costs. Women said they sometimes stopped attending appointments because they felt attendance was pointless; for example, if their husbands did not explain procedures or communicate their concerns. Others were unable to access a telephone to make an appointment or could not find the hospital or identify which bus to catch. Economic migrants sometimes skipped one or more follow-ups because their employers were reluctant to release them and they feared losing their job. Asylum seekers and failed asylum seekers wanted to attend appointments but were detained or dispersed by immigration services to areas away from their midwife. One asylum seeker with HIV stated that when she was detained for 2 months, she was denied access to maternity care and retroviral medication. Asylum-seeking women were sometimes preoccupied with resolving immediate crises, or attending solicitors’ appointments to discuss their asylum case, and tended to prioritise these matters over attending antenatal follow-ups. New migrant women often moved home frequently, sometimes at short notice. Sometimes they forgot, or lacked time, to notify maternity services about their change of address and could not be contacted to arrange follow-ups. Lack of continuity of care influenced the quality of patient–midwife relationships and sometimes affected women’s confidence to attend follow-ups. Some 50% of women respondents reported not having the name of a midwife they could contact when needed. Lack of continuity made appointments less effective than those in which a prior relationship with women existed. Only 21 women (26%) attended antenatal classes. African respondents were least likely to attend (13%) and A8 migrants most likely to attend (50%). Lack of information about classes (44%), being unable to communicate with health-care staff (25%), and lack of transport (21%) or affordable transport (12%) presented the main barriers to attendance. Particular problems attending classes were experienced by asylum seekers and those who were undocumented and hiding to avoid deportation.